Posted by: notdeaddinosaur | July 24, 2012

How Not to Counsel Smokers

I just read an article in a recent edition of Medical Economics that, frankly, annoyed the crap out of me. Seems there was this doctor who went up to a guy at an airport and tried to stage a tobacco intervention (from his original article in the Seattle Times):

… I saw a man smoking under a large “NO SMOKING” sign. I stopped and asked him if he could read the sign.

He looked at it, and he said to me, “It says, ‘Mind your own G-damn business.’ ”

“No,” I told him. “It says there are people who love you and care about you, so please stop smoking.”

He swore at me — but then he put the cigarette out. Did what I say make him a nonsmoker? Probably not, but if it moved him one step forward along the path of becoming tobacco-free, it was worth it.

Granted he begins the Seattle Times piece by pointing out that he’d had a particularly bad week in terms of patients with tobacco-related illnesses. But then in his Medical Economics article, he goes on to bemoan the negative feedback he received, and tries to justify his actions with this:

 I believe it is my obligation to my patients and to all members of society to use the knowledge and experience I have to give people the opportunity to live more healthful and safer lives.

I know more about the overwhelmingly proven dangers and complications of smoking than the man at the airport does, and I believe he might be more willing to consider cessation if he knew what I know.

Hoo boy, where to start?

He is wrong for three separate reasons. Number one:

“I know more about the overwhelmingly proven dangers and complications of smoking than the man at the airport does”

No sir, you do not know that. He is a stranger. You have no idea what he knows or doesn’t know. He could be a cardiologist, or a pulmonologist, or an environmental engineer, or have any number of advanced degrees. He could be, and more than likely is, entirely aware of all of the same deleterious effects of tobacco as you are. Which leads me to the second reason you are wrong:

You are making the flawed assumption that the only reason anyone would choose to smoke is because of a knowledge deficit. They must not know about the dangers and complications of tobacco use, because no one who did would make the rational decision to use tobacco. Trust me: the vast majority of smokers are well aware of everything bad about smoking. The reasons for continuing their nasty, nasty habit are far more complex, mainly emotional in nature. You claim to be an experienced clinician. I find it hard to believe don’t understand this dynamic.

Finally, there’s this:

I believe it is my obligation to my patients and to all members of society [emphasis mine] to use the knowledge and experience I have to give people the opportunity to live more healthful and safer lives.

No, it’s not. At least not uninvited. You’re welcome to appear on television and radio broadcasts, give newspaper and magazine interviews in your quest to benefit “society” with your vast knowledge and experience. But you do not have the right to accost a stranger in a public place with an impromptu tobacco intervention. Yes, he was under a No Smoking sign. Yes, you can point out that specific transgression. But beyond that, you’re out of line.

Your main obligation is to your patients. In order to become your patient, a person has to walk in your door, (probably fill out a bunch of paperwork), and sit down with you. You have neither the right nor the obligation to go around spreading your “knowledge and experience” willy-nilly to the general public, and your arrogance in doing so gives the rest of us doctors a bad rap.

Furthermore, tobacco counseling is not — or shouldn’t be — the first thing you do in a patient encounter. You begin by taking a history, don’t you? Then you do a physical exam. You get to know your patient; all about their health, hopefully including why they smoke. Then and only then does it make sense to embark on a personalized discussion of smoking cessation.

How do you know the guy at the airport isn’t an addiction specialist who happens to be on his way back east to attend the funeral of a buddy killed in Iraq? How do you know his quit date isn’t tomorrow and this is the last cigarette he’ll ever have, except now you’ve aggravated him to the point of changing his mind? It’s like lambasting someone who’s twenty pounds overweight before finding out they’ve already lost sixty pounds on their own. You have no context. And you have no right to accost a stranger in public, to the extent that he is not doing anything illegal and minding his own business, with whatever holier-than-thou aspirations you may have of dispensing your great “knowledge and experience…to give people the opportunity to live more healthful and safer lives.”

Mind your own G-damn business.



  1. A. Men. I’ve been a hypnotist since 2003, soon-to-be-ex-smokers are one of my largest market segments, and self-righteousness simply Does. Not. Work.

    (In fact, a fair number of people get defensive just hearing I’m a hypnotist, assuming I’m going to get self-righteous on them.)

    Knowledge deficit indeed. Just not where most people think it is. Have you ever read ‘Switch’ by Chip and Dan Heath?

  2. I’m not sure what they guy thought he was going to accomplish, seems to me he was lucky he got just cussed out rather than punched out.

  3. Thank you.

  4. There is a sign in my office saying “If you smoke, I fume.”

  5. My father used to have a sign in his office that said, “Smoking is a breath freshener for people who eat shit.” (Don’t get your undies in a knot. He only showed it to people who could take a joke.)

  6. Delivery definitely matters. Counseling a woman who had recently been an in-patient, she said the only thing the doctor had said to her about smoking was, “You seem like an intelligent woman, why are you smoking?” After which she wasn’t inclined to tell him much of anything. He didn’t know she’d made a quit attempt in the past few months, or that she’d already tried every pharmacotherapy on the market. She said if she’d been quicker, she would have replied, “You seem like an intelligent man, why do you think?”

  7. I seriously wonder sometimes if a fraction of the negative health outcomes associated with smoking are a result of reluctance to see a doctor, because the patient doesn’t want to sit through another lecture about smoking. I have a family member who has tried repeatedly to quit, and avoids doctors whenever possible because, no matter what his complaint, it gets linked to a lecture on smoking.

    I’ve also wondered the same thing about weight. Back when I was unable to choose my own doctor, I once wound up with a kidney infection because the last time I’d been in — with a sore throat, swollen lymph nodes, a fever, and the information that several people I worked with had strep throat — I was told that it was due to the acid in all the sodas I must be drinking (false assumption) and instructed to lose weight. (Because, apparently, being 30 pounds overweight causes strep throat.) After that, I was determined not to go back if I could help it. So a routine UTI turned really, really nasty, because I didn’t want to be lectured about my weight again.

  8. […] How Not to Counsel Smokers by Lucy E. Hornstein […]

  9. […] How Not to Counsel Smokers by Lucy E. Hornstein […]

  10. Should the doctor try to “play” doctor with someone he does not have a therapeutic relationship? NO. Is he being presumptuous? yes. But let’s be honest about something this guy is smoking under a NON SMOKING SIGN IN A PUBLIC AIRPORT WAITING AREA. Dammit, he doesn’t have the right to expose me or my loved ones to the exhaled shit from his lungs in a posted NONSMOKING AREA. I presume and hope you are well aware of secondhand smoke exposure. Frankly, that is where YOU ARE WRONG DINO.

  11. […] How Not to Counsel Smokers by Lucy E. Hornstein […]

  12. To the July 29 Anonymous:

    And if the doctor had said “Hey, this is a non-smoking area; please put that out,” I would be 100% behind him. But he made it clear that his mission here wasn’t to tell total strangers not to smoke in non-smoking areas, but to tell them that they shouldn’t smoke AT ALL, ever, anywhere. That difference matters.

  13. Well said, Ma’am.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s


%d bloggers like this: